October 14, 2026

Virginia Department of Medical Assistance Services

Attention: Syreeta Stewart, Regulatory Coordinator

600 E. Broad St., Suite 1300

Richmond, VA 23219

Submitted via the Virginia Regulatory Town Hall (Forum ID 2982)

RE: Proposed Revisions to the Mental Health Services Manual, Appendix D – Applied Behavior Analysis (draft dated 9/21/26)

Dear DMAS Behavioral Health Team:

My name is Callie Plattner, and I am the Chief Clinical Officer of Mosaic Pediatric Therapy. I am a doctoral-level Board Certified Behavior Analyst (BCBA-D) and Licensed Psychological Associate, a two-time past President of the North Carolina Association for Behavior Analysis, and a subject matter expert for the Behavior Analyst Certification Board (BACB) and the Council of Autism Service Providers (CASP). Mosaic provides ABA therapy to children and families affected by autism in Virginia and North Carolina. In Virginia, we operate eight clinics in the Richmond region and Southwest Virginia, with a ninth opening by the end of the year, and employ over 300 staff members.

We pride ourselves on our relentless focus on maximizing client outcomes through quality service delivery. This is not easy work. Mosaic has invested for years in measuring, analyzing and modeling clinical outcomes for every child we serve. On average, our patients achieve clinical outcomes that are 40–60% better than the published ABA benchmarks.¹ And our patient/family net promoter score (NPS) of 82 places us in the top 3% of ABA providers nationally.²

We share DMAS's goals of medically necessary, individualized and well-documented ABA services, and we are unequivocally supportive of stronger program integrity. We especially welcome the commitment that every ABA request will be reviewed under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) criteria before a denial. Our central concern is the proposed 20-hour weekly limit, which we believe would restrict medically necessary care for the children who need it most. We address it first, followed by the diagnostic and provisional-diagnosis changes.

Summary of requested changes

1. The 20-hour weekly limit (p. 28)

What the draft changes

Today, the manual states that "services are authorized based on medical necessity," and requests over 20 hours per week require a structured schedule. The draft strikes the schedule requirement and adds a ceiling: services are authorized based on medical necessity "and may not exceed 20 hours per week, except as authorized under EPSDT review." Every request above 20 hours would move to a separate EPSDT process with added documentation, including a description of the interventions planned "for each timeframe."

This is a material change. The current standard asks whether more hours are medically necessary. The proposed standard presumes they are not.

A ceiling is inconsistent with EPSDT

Under EPSDT, children under 21 are entitled to medically necessary services to correct or ameliorate their conditions (42 U.S.C. § 1396d(r)(5)). The Centers for Medicare & Medicaid Services (CMS) issued its State Medicaid & Children's Health Insurance Program Applied Behavior Analysis Toolkit (the Toolkit) in August 2026 to guide state ABA coverage policy. It is explicit: "for EPSDT-eligible children, states must cover ASD-related interventions that are coverable under section 1905(a) when the services are medically necessary." It warns that utilization review relying "solely on singular factors such as diagnosis codes, age, or preset hourly thresholds, risks conflicting with EPSDT," and that thresholds "should not operate as absolute caps when additional medically necessary services are needed." A presumptive limit, with individualized review available only as an exception, is exactly what CMS cautions against.

In practice, a number written into the manual as a ceiling becomes the default. This is already happening: Virginia providers report that at least one managed care organization (MCO) issues at least partial denials on every request above 20 hours, using generic language rather than an individualized EPSDT review. Codifying a ceiling would make that the norm. Federal rules require MCOs to furnish services in an "amount, duration, and scope that is no less than" under fee-for-service Medicaid, including EPSDT for children (42 C.F.R. § 438.210(a)(2)). Denial notices must also state the reasons and give families access to the medical necessity criteria used (42 C.F.R. § 438.404(b)). Generic denials that skip individualized EPSDT review do not meet these standards, and a ceiling in the manual would invite more of them.

The limit falls hardest on the children with the greatest needs

Twenty hours sits below the range for comprehensive treatment. The current (third) edition of CASP's practice guidelines, as CASP presented to DMAS's ABA Utilization Workgroup on September 22, describes focused treatment as 10–25 hours and comprehensive treatment as 25–40 hours per week of direct treatment, set case by case rather than by a fixed number. Under the draft, every child who needs comprehensive treatment would require an exception.

This is not a cap on outliers. DMAS's own data, presented to the ABA Utilization Workgroup on September 22, show that in 2025 about 71% of children ages 0–4 and 53% of children ages 5–10 received 20 or more hours of ABA in a week. These two age groups make up roughly 90% of the children served. The draft would therefore require EPSDT review, and risk reductions, for most of the youngest children in the program, the age group in which intensity matters most. In Mosaic's experience, these children typically have significant deficits across communication, social and adaptive skills, and often self-injury, aggression or elopement. The Toolkit's own best practice is that providers "must consider the individual's age, ASD symptoms and severity, needs, tolerance, and response to treatment." A fixed limit considers none of these.

The research supports individualized intensity, not a uniform ceiling. The most recent individual participant data meta-analysis, pooling 15 controlled studies of children ages 2 to 6, found that children receiving 26 to 40 hours per week gained an average of 22.4 IQ points, roughly double the 11.1-point gain of children in low-intensity programs, with parallel gains in adaptive behavior and autism severity (Eldevik et al., 2026). For children under 7, Granpeesheh et al. (2009) found no point of diminishing returns up to roughly 40 hours per week. The Toolkit also notes studies that found no association, most prominently Sandbank et al. (2024), but a reanalysis of that same dataset found significant, clinically meaningful dose effects once pre-intervention IQ was controlled (Frazier et al., 2025). The Toolkit concludes that "there is no consensus on a set number of hours recommended for treatment." We agree, and that conclusion applies equally to a fixed 20-hour ceiling. If no single number fits every child, a limit applied to every child is the wrong tool.

Underserving young children has lasting costs. Lifetime costs for an autistic person in the United States have been estimated at $1.4 million to $2.4 million, driven largely by special education and lost productivity (Buescher et al., 2014). In a U.S. Medicaid-enrolled cohort, shorter delays to early intensive behavioral intervention were associated with higher rates of general education placement (Dimian et al., 2021). A cap that saves hours at age three may cost the Commonwealth far more over that child’s lifetime. 

CMS guidance and Virginia's current policy: review, not caps

The Toolkit lists "service hour thresholds that trigger review" as a feature of effective prior authorization, and states that higher intensity "should only be authorized based on the [individualized treatment plan's] documentation of needs and goals that warrant extensive treatment." This is CMS guidance to every state, not one state's choice. Virginia already has a policy that meets it: DMAS's December 2025 ABA bulletin requires requests above 20 hours to include an individualized schedule and clear justification, and the Toolkit features that policy as a "State Spotlight" on high-intensity review. North Carolina, also highlighted in the Toolkit, takes the same approach, requiring plans over 16 hours per week to be reviewed and approved rather than capped. The draft would replace the approach CMS highlighted with a ceiling. Virginia can meet DMAS's program-integrity goals by keeping it.

Addressing the Department's concerns directly

We understand the concerns behind this proposal. The Toolkit reports a 22% increase in average weekly hours since 2021. It also warns that very high-intensity schedules can "take on the characteristics of respite care and childcare." We share these concerns, and we agree that 40 hours should never be a default. The right response is to scrutinize high-intensity requests closely, not to limit every child. A review threshold paired with the documentation standard below would:

• require a clinical justification tied to assessment results for every hour above 20;

• require schedules that distinguish skill-building from breaks and downtime, while recognizing that mealtime, toileting, dressing and other self-care routines are often treatment targets themselves. The Toolkit acknowledges that ABA "may focus on activities such as food selectivity or enuresis." Whether time is therapeutic should depend on whether the activity has programmed objectives, data collection and documentation tied to an active goal, not on whether it looks recreational;

• require goals and criteria for reducing intensity, so high-intensity plans are time-limited by design; and

• give DMAS and MCOs a clear basis to deny requests that are not supported.

How Mosaic manages intensity

Mosaic's practice shows that intensity can be managed responsibly without a ceiling. Every hours recommendation follows a structured medical-necessity model and is reviewed against standardized outcome measures (the Vineland, the VB-MAPP Barriers Assessment and the Autism Impact Measure), using the outcome-measurement framework my colleagues and I published this year (Cox et al., 2026). Higher intensity is reserved for children whose assessments show it is needed and is tapered as goals are met. DMAS can require this standard of every provider.

Practical consequences

• Appeals and administrative cost. When services are reduced, families are entitled to notice and a fair hearing, and in managed care, benefits may continue pending appeal (42 C.F.R. Part 431, Subpart E; 42 C.F.R. § 438.420). Applied to thousands of children now above 20 hours, a ceiling could generate appeals costing DMAS, MCOs and families more than up-front clinical review.

Recommendations

1. Replace the ceiling with a review threshold. Recommended language: "Services are authorized based on individualized medical necessity. Requests for direct treatment exceeding 20 hours per week require additional documentation supporting the requested intensity and are reviewed under EPSDT criteria. The 20-hour threshold is not a limitation on medically necessary services."

2. Count direct treatment only (e.g., 97153 and 97154), consistent with CASP's guidelines, so that clinically important caregiver training or supervision does not push a child over the threshold.

3. Use a clinical documentation standard. Each treatment plan should state whether the program is focused or comprehensive, the clinical justification for the hours, and the goals and criteria for reducing intensity. Schedules should show the distribution and therapeutic purpose of services, for example "4 hours per day, 5 days per week, targeting individualized service plan (ISP) goals in communication, social skills and behavior reduction," rather than the intervention planned for every timeframe.

4. Make EPSDT determinations individualized. No request should be denied solely because hours exceed a threshold, and MCO decisions should document an individualized review rather than generic language.

5. Protect children already in care. Apply the new standard at each member's next reauthorization, with at least 90 days for implementation, so no child's hours are reduced while review is pending.

6. Let the data guide any future threshold. Before setting a fixed number, we ask DMAS to publish data on authorizations above 20 hours, including the number of children, their ages and severity, and their outcomes, and to review it with the ABA workgroup. Mosaic will contribute its outcome data to that review.

2. Diagnosis and the provisional-diagnosis pathway (pp. 24, 28–31)

ASD diagnosis requirement (p. 24). We understand the concern behind this change. DMAS's data show that 88% of children receiving ABA in 2025 had an autism diagnosis, and one plan reported to the ABA Utilization Workgroup that non-ASD diagnoses, led by ADHD, accounted for 12.2% of its 2025 ABA spending. We agree that comprehensive ABA should be reserved for autism. But focused, function-based treatment for severe behavior can be medically necessary for children with other diagnoses. We ask DMAS to state in the admission criteria that youth without an ASD diagnosis may receive focused ABA for severe behavior through individualized EPSDT review.

Diagnostic documentation (p. 28). The draft requires the comprehensive diagnostic evaluation to be "conducted in-person." We agree that every evaluation should include in-person direct assessment. The Toolkit prefers in-person evaluation but recognizes a role for telehealth when families lack "qualified providers available within a reasonable travel distance," and its implementation checklist asks that evaluations not be "100 percent telehealth." We recommend a hybrid model: direct assessment such as the ADOS in person, with developmental history, caregiver interviews, records review and feedback permitted by telehealth. A fully in-person requirement would reduce diagnostic capacity, particularly in rural regions such as Southwest Virginia, where Mosaic operates three clinics. We also recommend allowing correction of missing administrative items, such as an evaluator's National Provider Identifier (NPI), rather than denial.

Align with Virginia's own diagnostic initiatives (pp. 28–29). Through the Virginia Mental Health Access Program (VMAP), the Commonwealth trains primary care clinicians "to screen and diagnose young children for autism" using the STAT. The draft, however, lists the STAT only as a screening tool and names the ADI-R, ADOS and CARS as diagnostic examples. DMAS should state that STAT-based diagnoses by trained primary care clinicians qualify. Otherwise, families diagnosed through the state's own initiative would need a second evaluation, adding months of delay and lengthening specialty waitlists.

Provisional diagnosis (pp. 28–31). We strongly support letting young children begin ABA while awaiting evaluation. The Toolkit notes that "some families [wait] two years between ASD screening and diagnosis" (Chen et al., 2023), and recognizes that states may authorize "limited, time-bound ABA services" under EPSDT in these circumstances. To make the pathway workable:

• Use one screening standard. Children 36 months and under must submit a RITA-T or STAT screening; children 37 months to 5 years do not. One validated-screening standard should apply to the whole age range, and it should include the M-CHAT-R/F, the screener most widely used in pediatric primary care.

• Allow a provisional diagnosis after borderline findings. For children under 36 months whose evaluation yields borderline findings, the evaluating clinician should be able to issue a provisional diagnosis valid for six months, followed by reassessment, as North Carolina allows.

• Accept family-provided documentation. Appointment and waitlist proof "obtained directly from the evaluating entity" (p. 31) places providers between families and evaluators. Confirmation letters or patient-portal records provided by the family should suffice.

• Account for evaluator capacity at 6 and 12 months. When a family has an active appointment or waitlist placement, the absence of a completed evaluation at 6 months, or a final diagnosis at 12 months, reflects evaluator capacity rather than clinical need. Services should continue while the child shows clinical benefit, and item 3 (p. 31) should carry the same appointment and waitlist language as item 2.

• Include older children. Older children face the same waitlists and are often identified later, particularly girls. DMAS should state that they may receive time-limited services under EPSDT review.

Closing

The single most important change DMAS can make is to replace the 20-hour ceiling with a review threshold, preserving accountability while ensuring the children with the greatest needs receive the care that is medically necessary for them. We would welcome the opportunity to share our full outcome data with DMAS and the ABA workgroup as the Department finalizes Appendix D.

Sincerely,

Callie Plattner, PhD, LPA, BCBA-D

Chief Clinical Officer, Mosaic Pediatric Therapy

cplattner@mosaictherapy.com · 980-202-7437

Sources

1. Mazurek, M. O., et al. (2020). Autism Research, 13(11), 1867–1879.

2. BHCOE (2022). Strategic Benchmark Report: Parent & Guardian Satisfaction.

3. Cox, D. J., Godwin, J., Filer, M. R., & Plattner, C. (2026). A guide to choosing a balanced outcomes measurement portfolio for ABA organizations. Behavior Analysis in Practice. https://doi.org/10.1007/s40617-026-01164-2

4. CMS (2026). State Medicaid & Children's Health Insurance Program Applied Behavior Analysis Toolkit.

5. CASP (2024). Applied Behavior Analysis Practice Guidelines for the Treatment of Autism Spectrum Disorder (3rd ed.), as presented to the DMAS ABA Utilization Workgroup, September 22, 2026.

6. Virginia DMAS (September 22, 2026). ABA Utilization Workgroup, Meeting #1 (slide deck).

7. Virginia Mental Health Access Program (VMAP). Free STAT Certification. vmap.org.

8. Eldevik, S., et al. (2026). Autism Research, 19(1), e70169.

9. Sandbank, M., et al. (2024). JAMA Pediatrics, 178(8), 763–773.

10. Frazier, T. W., Chetcuti, L., & Uljarevic, M. (2025). Evidence that intervention dosage is associated with better outcomes in autism. JAMA Pediatrics, 179(1), 101–102.

11. Granpeesheh, D., et al. (2009). Research in Autism Spectrum Disorders, 3(4), 1014–1022.

12. Buescher, A. V. S., Cidav, Z., Knapp, M., & Mandell, D. S. (2014). JAMA Pediatrics, 168(8), 721–728.

13. Dimian, A. F., Symons, F. J., & Wolff, J. J. (2021). Journal of Autism and Developmental Disorders, 51(4), 1054–1066.

14. Chen, Y. H., et al. (2023). Cited in CMS (2026).